Notes: Basic Issues in Bioethics – Utilitarianism and Related Theories

Bentham and the Principle of Utility

• Utilitarianism is the ethical theory most prominently associated with the principle of utility, also called the great­est happiness principle. It judges actions by their consequences for overall happiness or welfare.
• Key idea: Actions are right in proportion as they tend to promote happiness, and wrong as they tend to produce the reverse of happiness.
• Focus: Consequences of actions, not intrinsic features of the actions themselves. This makes utilitarianism a teleological and consequentialist theory.
• Bentham and Mill introduce the standard for judging the rightness of actions via outcomes for all affected.
• Formal expression (utilitarian calculus):
  • Define the utility of an action a as the total happiness produced across all affected individuals. If ui(a) denotes the happiness of person i under action a, then the total utility is U(a) = \sum{i=1}^{N} u_i(a).
  • The right action is the one that maximizes this total utility:
    a^* = \underset{a \in A}{\arg\max} \, U(a).
• This standard is often summarized as the “greatest happiness for the greatest number.”
• Happiness is the intrinsic good in classical utilitarianism: the aim is to increase happiness and reduce unhappiness for all affected.
• Utilitarianism as a theory is both teleological (end-focused) and consequentialist (outcome-focused).
• The right action, in Mill’s formulation, depends on promoting the greatest overall happiness, not just the agent’s or a particular group’s happiness.

Bentham, Mill, and their formulations

• Bentham (1748–1832) and Mill (1806–1873) developed classical utilitarianism; their variants converge on evaluating actions by their tendency to maximize happiness for the greatest number.
• Bentham’s calculus of pleasures and pains attempted to measure utility by factors such as:
  • intensity, duration, certainty, propinquity (remoteness in time), fecundity, purity, and extent.
  • In practice, they proposed a numerical scoring to compare actions, though he does not specify the exact units or measurements.
• Mill adds a qualitative distinction: some pleasures are higher than others (higher vs lower pleasures).

Mill’s Higher and Lower Pleasures

• Mill argues that some pleasures are intrinsically more valuable than others (e.g., intellectual pleasures over purely sensual pleasures).
• Pleasures of the mind (knowledge, beauty, love, friendship) are superior to bodily pleasures.
• The standard for judging pleasures is: would you choose the higher pleasures for yourself and, importantly, would a competent judge prefer them for others as well?
• The “benevolent spectator” is a hallmark: we should view actions from the standpoint of an impartial observer who considers everyone’s interests on equal footing.
• The motto: happiness for all, with impartial concern for every person’s welfare.

Teleological and Consequentialist Nature; Instrumental Value

• Utilitarianism is teleological: it judges actions by their outcomes toward a general end (happiness or utility).
• It is also consequentialist: the moral rightness of an action is determined by its consequences, not by motives alone or intrinsic features of the act.
• Some later formulations (pluralistic utilitarianism) argue that happiness is not the only intrinsic good; other intrinsic goods can be weighed.
• Teleological basis in general: external goal or purpose (happiness/utility) guides normative judgments.

The Principle of Utility and Its Variants

• The basic idea remains: the right action is the one that yields the best balance of happiness over unhappiness for all concerned.
• “Happiness” is treated as the primary intrinsic good, but there is a recognition that some philosophers favor a broader set of intrinsically valuable goods.
• The principle is often framed as a standard for evaluating both individual actions and public policies.

The Pluralistic View: Intrinsic Goods Beyond Happiness

• Some critics argue that we should broaden the utility notion beyond happiness to include a range of intrinsic goods: knowledge, beauty, love, friendship, liberty, health, etc.
• Pluralistic utilitarianism asks that we consider the entire spectrum of intrinsic goods when evaluating actions.
• In this view, the right action is the one that maximizes the sum of intrinsic goods, not merely happiness.
• In discussions, the language often shifts to “greatest sum of intrinsic goods” rather than “greatest happiness.”

Foundations of Bioethics: Act Utilitarianism vs Rule Utilitarianism

• Act Utilitarianism
  • An act is right if, and only if, no other act in the given circumstances would yield higher utility.
  • Pros: highly case-sensitive; can adapt to unique situations.
  • Cons: difficult to guarantee consistent judgments across similar cases; trouble predicting all consequences; can require violating deeply held moral duties (e.g., promises) if doing so maximizes utility.
  • Examples used in bioethics discussions include choosing between extreme outcomes for patients where consequences are hard to know in advance (e.g., infant with severe impairment vs resource allocation).
• Rule Utilitarianism
  • The rightness of an action is determined by whether it conforms to a rule whose general adherence, across many situations, maximizes utility.
  • Pros: provides stability, predictability, and fairness; protects commitments like keeping promises; supports social cooperation.
  • Cons: rules may conflict in particular cases; a large set of rules can be unwieldy; rules can occasionally be outweighed in special circumstances, leading to escape clauses.
• Key illustration: Keep your promises vs exceptions
  • A rule like “Keep your promises” generally yields higher utility, but rule utilitarianism allows escape clauses such as “Keep your promises unless breaking them is required to save a life.”
  • This example highlights why some rule utilitarians worry about how many exceptions a rule can tolerate without corroding trust.
• Medicaid/Medicare-like program example (policy level)
  • At the policy level, rule utilitarianism argues for rules that protect the integrity of a program (e.g., fraud prevention rules) so that the program can maximize utility for all beneficiaries.
  • Critics worry that rules designed to maximize overall utility might produce unfair results for some individuals or groups; this raises justice concerns not always captured by simple utility calculations.

Act Utilitarianism vs Rule Utilitarianism: Practical Implications in Bioethics

• Act utilitarianism is responsive to particular cases (e.g., the infant with an open spine or severe impairments) by evaluating the likely outcomes of different actions for that case.
• Rule utilitarianism aims to prevent systemic harms by adhering to rules that generally maximize utility, such as not fraudulently billing a program or dying a patient through inaction when action would yield greater overall benefit.
• Critics argue that rules, if too rigid or too numerous, may fail to capture nuanced ethical obligations. Conversely, act utilitarianism may justify violating obligations (promises) in pursuit of greater overall good.

Objections and Difficulties for Utilitarianism in Bioethics

• Predicting consequences is inherently uncertain; even severe impairment cases may have unpredictable outcomes.
• The obligation to keep promises can clash with utilitarian calculations; if keeping a promise yields less overall utility than breaking it, act utilitarianism might permit or require breaking it, which many find troubling.
• The “open spine” infant case demonstrates conflicts between respect for persons, potential quality of life, family considerations, and resource allocation.
• The issue of justice: utilitarianism tends to favor overall good, but may overlook the rights and welfare of minorities or individuals who suffer for the greater number.
• Critics argue that a society organized purely around utility could collapse due to lack of social cohesion, trust, and enforceable norms; social policy requires not just aggregate welfare but fairness and justice.
• The problem of whether happiness or utility can serve as a universal standard for all moral deliberation, especially when people’s values differ widely.
• Some philosophers insist that justice, rights, and moral duties cannot be reduced to an aggregate of happiness; thus utilitarianism may be insufficient as a complete ethical theory for bioethics.

Preference Utilitarianism (A notable variant)

• Preference utilitarianism replaces happiness with preference satisfaction as the ultimate aim.
• People can rank preferences and even express uncertainty about risk; decisions may weigh how much risk individuals are willing to take to realize a given preference.
• Example: A young woman with a hip injury may be willing to accept the risk of surgery to restore years of active life; an elderly woman may prefer to avoid surgery due to health risks and fewer expected years of benefit.
• Preferences can be about social choices as well as individual choices, leading to policy questions like whether to provide universal basic health care, funded by taxes, vs preserving other social goods (education, defense).
• Crucial challenge: some preferences are unacceptable (e.g., preferences for mass murder, child abuse, torture). A pure preference utilitarian framework cannot treat all preferences as equally valid; we need criteria to distinguish acceptable from unacceptable preferences.
• Thus, many critics argue that preferences alone cannot ground morality without additional principles (e.g., justice, rights, non-maleficence).

Decision Theory, Preferences, and Social Policy

• Some theorists use decision theory to model how rational agents should choose under risk and uncertainty, incorporating both preferences and probabilities of outcomes.
• The use of decision theory can yield a more explicit, rule-guided approach to policy decisions (e.g., healthcare allocation) by quantifying trade-offs between preferences, costs, and risks.
• There is an ongoing debate about whether policies should be evaluated primarily by happiness, preference satisfaction, or a broader set of intrinsic values.
• The life expectancy and viability of medical procedures can be modeled as expected utilities, balancing patient preferences, clinical outcomes, costs, and risks to broader society.

The Missing Notion of Justice in Classic Utilitarianism

• A central critique is that utilitarianism, in its classical form, does not by itself guarantee justice or fairness for individuals. It can justify sacrificing minority interests if doing so increases aggregate happiness.
• Mill acknowledged the need for a principle of justice within utilitarian reasoning, but many contemporary philosophers argue that justice cannot be fully derived from the principle of utility alone.
• This tension has led to attempts to reconcile utilitarian ideas with principles of justice (e.g., rule utilitarianism, preference ethics, aggregation rules with restrictions).

What About Kant? (Overview in this material)

• The material includes a section labeled "Kant’s Ethics" and contrasts with utilitarianism, emphasizing rational decision making and universalizable maxims.
• Kantian ethics centers on acting from duty and treating persons as ends in themselves, not merely as means to an end. It emphasizes autonomy and the intrinsic worth of rational beings, independent of the consequences.
• In the discussed material, Kantian perspectives are presented as a foil to utilitarian calculations, highlighting the tension between universal moral duties and consequentialist assessments of outcomes.

Key Takeaways for Bioethics Reasoning

• Utilitarianism provides a clear, outcome-focused framework for evaluating actions and policies, with a strong emphasis on overall welfare and impartial consideration of all affected.
• Act utilitarianism offers case-by-case assessment but risks inconsistency and neglects social trust (promises, rules).
• Rule utilitarianism emphasizes the stability of rules to promote long-run utility and social cooperation but must resolve conflicts among rules and avoid overly stringent or conflicting rule nets.
• Mill introduces the qualitative distinction between higher and lower pleasures, arguing that some kinds of happiness matter more than others and that competent judges would prefer higher pleasures for all.
• Preference utilitarianism foregrounds individuals’ actual desires and risk tolerances, but must grapple with unacceptable or immoral preferences and with differences in value across individuals and cultures.
• A robust ethical framework for bioethics often requires incorporating notions of justice, rights, and respect for persons (Kantian ideas) alongside utilitarian reasoning to avoid endorsing inhumane or unfair outcomes.

Quick Reference: Key Terms and Ideas

• Principle of Utility / Greatest Happiness Principle: Actions are right as they promote happiness overall; wrong as they promote unhappiness.
• Teleological ethics: Moral rightness determined by the end/state achieved (the good produced).
• Consequentialism: Moral worth of an action depends on its consequences.
• Act Utilitarianism: Evaluate each action by its own consequences; the right action yields the greatest utility among available options.
• Rule Utilitarianism: Evaluate rules by the consequences of adopting those rules; the right rules maximize utility when generally followed.
• Bentham’s calculus of pleasure and pain: proposed factors to measure utility (intensity, duration, certainty, propinquity, fecundity, purity, extent).
• Mill’s higher vs lower pleasures: Intellectual and moral pleasures are superior to mere physical pleasures.
• Benevolent spectator: an impartial observer whose verdict reflects universal welfare considerations.
• Preference Utilitarianism: Utility is the satisfaction of preferences; may require distinguishing acceptable from unacceptable preferences.
• Justice in Utilitarianism: Critics argue that classic utilitarianism lacks a principled account of justice; many see a need to integrate justice as a core moral constraint.
• Kantian Ethics: Duty-based framework emphasizing universal maxims and treating persons as ends in themselves; autonomy and the moral law.

egin{aligned} U(a) &= \sum{i=1}^{N} ui(a) \ a^* &= \underset{a \in A}{\arg\max} \, U(a) [,] \text{and} \ \ ext{Rule utility: } &\mathcal{U}(R) = \text{utility of following rule }R \ \text{across applicable cases} \end{aligned}